(Pleural effusion)

.. ..
,
(pleuritic chest pain)


75

1.

underlying cardiopulmonary disease
underlying
cardiopulmonary disease
2.
lateral, anterior
posterior diaphragm
, referred pain
central diaphragm
3. , (paroxysmal
nocturnal dyspnea),
congestive heart failure

 (dullness on percussion), vocal fremitus
vesicular breath sound 500 .
1,000 . scapula
egophony
bronchial breath sound

1.
upright <
75 . lung marking dome diaphragm (
underexposure) blunt posterior costophrenic angle
lateral film (150-200 .) blunt lateral costophrenic angle PA film (200-300 .)
( 1) 500 . homogeneous opacity
costophrenic angle meniscus sign lateral medial(1)
( 2)

1 Right pleural effusion (blunt costophrenic angle)

 2 Left pleural effusion (meniscus sign)
opacity 1/3-1/2 hemithorax 1
massive opacity mediastinum
hemithorax (2) ( 3)

3 Massive left pleural effusion with shifting of mediastinum to the right ()

hemithorax
total opacification mass effect
endobronchial obstruction atelectasis (2)
 CXR supine PE hemithorax
generalized hyperdensity hemithorax lung marking ground-
glass appearance(2) ( 4)

4 Left pleural effusion (supine position)

(<200 .) diaphragm subpulmonic
effusion , transudate exudate subpulmonic
pleural effusion pleural effusion congestive heart failure
diaphragm (2) diaphragm 2 .
subpulmonic pleural effusion pseudo-diaphragmatic elevation
diaphragm gastric air
bubble diaphragm 2 . ( 4A)
diaphragm lateral ( 5A) lateral
decubitus ( 4B, 5B) (1, 2)
 4A Left subpulmonic effusion (upright)

4B Left subpulmonic effusion (left decubitus)

 5A Right subpulmonic effusion (upright)

5B Right subpulmonic effusion (right decubitus)

loculation
adhesion tumor (pseudotumor) (
6A) ( 6B)(1)
loculation empyema, hemothorax,
 6A Two loculations (pseudo-tumor) lateral view 6B
lateral decubitus ( 100 .)
dependent lateral chest wall chest wall pleural effusion 1
. lateral decubitus
chest wall pleural effusion 1 .
(3)
2.
(diagnostic thoracentesis)
congestive
heart failure congestive heart failure
, ,
(3, 4)
ultrasound guided
 ultrasound mark
(3)
transudate exudate
exudate Light (4)
1) pleural fluid to serum protein ratio 0.5
2) pleural fluid to serum LDH ratio 0.6
3) pleural fluid LDH 2 3 LDH
transudate exudate (
CHF ) protein albumin
3.1 g/dL(5) ( protein) 1.2 g/dL(6)
( albumin) transudate
3.
closed
blinded ( 40-50)(7)
( 50-70) (7) CT scan
(4, 8)
thoracoscopy pleuroscopy 90(4)

exudative pleural effusion
1.

, pulmonary infarct, postcardiac
injury syndrome, trauma chylothorax cholesterol pleural effusion
hematocrit hemothorax pleural fluid hematocrit
 50% hematocrit chest tube hematocrit
pleural fluid
hematocrit true bloody fluid trauma
trauma
platelet macrophage hemoglobin
inclusion
2.
3. glucose pH
4. cytology
5. adenosine deaminase (ADA)

anticoagulant
(9)
transudate 1,000 .
exudate 1,000 .(3)
10 .
0.5 . 70% alcohol
Wright stain neutrophil exudate
acute inflammation parapneumonic effusion, pancreatitis, pulmonary embolism,
(< 2 )(10) eosinophil (>10%
)
trauma
2 trauma asbestos, parasites,
Churg-Strauss syndrome lymphocyte (>50% )
 lymphoma(11)
lymphocyte (T cell B cell) lymphoma B cell
(80% B cell)(12)
pH glucose
pH transudate 7.45 7.55 exudate 7.3 7.45
pH 7.3 (acid)
empyema, complicated parapneumonic effusion, rheumatord
pleurisy, esophageal rupture malignancy, TB, lupus pleuritis 20-30
pH glucose 60 mg/dL(12)
cytology
cytology 40
90(12) 60 3
90(3) advanced
adenocarcinoma lymphoma (12)

(atelectasis) hypercoagulable state pulmonary embolism
radiation cytology
adenosine deaminase (ADA)
ADA (purine)
differentiation lymphoid cell
lymphocyte TB malignancy ADA
TB (13) ADA 60 IU/L
cut-off ADA 40 60
IU/L (40 IU/L) (sensitivity) 90-100
(specificity) ( 85-95)(12)
ADA 60 IU/L 84-100 96-100(10)
ADA ADA lymphocyte neutrophil
0.75 (14)
adenosine deaminase (ADA)
malignancy ) ADA
ADA 40 IU/L

1.
Gram, acid-fast modified acid fast, Wright
2. parapneumonic effusion
3.

chemistry , esophageal
rupture amylase
3 4
1 4
CT chest CT
biopsy medical surgical
thoracoscopy
transudative pleural effusion
congestive heart failure, hypoalbuminemia, hepatic hydrothorax,
nephrotic syndrome atelectasis, peritoneal dialysis, trapped lung,
constrictive pericarditis, urinothorax, extravascular migration of central venous catheter (saline),
acute superior vena cava obstruction
exudative pleural effusion
transudative exudative pleural effusion ,
1

Transudative pleural effusion therapeutic

thoracentesis (3)

1. malignant pleural effusion

systemic treatment lymphoma, breast cancer 1 3
malignant pleural effusion lung cancer
5 10 primary tumor (15)
repeated thoracentesis
(chest tube) pleurodesis
pleurodesis fibrous adhesion
visceral parietal pleura reaccumulation
lung expansion pleurodesis
doxycycline 500 50-100 . clamp 2
clamp 150 .
150 . 72
chest tube pleural catheter

 2. Parapneumonic effusion(16)
3
1. Simple uncomplicated free-flow, ,
60 g/dl Gram stain
drainage
2. Complicated (> hemithorax)
( 60 g/dl) LDH 1,000 U/mL
Gram stain loculation fibropurulent
pleural peel loculation
fibrinolytic agent streptokinase 250,000 units urokinase 100,000 unit
50-100 . chest tube 2-4 3 drainage

3. Empyema Gram stain
culture
thoracoscopic
drainage decortication
28-36 Fr
24-48
50 .
 1 transudative exudative pleural effusion
, ( 1 primer of
differential diagnosis of pleural disease: Manual of pleural procedure Colt HG, Mathur PN(7)
 predominate cells pH diagnostic comments
features
Transudates
CHF, cirrhosis, NS, PD, urinothorax straw lymphocyte, mesothelial cell >7.4 PD-glucose>300 cirrhosis >70%
Exudates
Infection
uncomplicated parapneumonic PMN >7.3 LDH<500, resolves with antibiotic
effusion glucose>60
empyema PMN <7.1 LDH>1000, requires antibiotic, immediate
glucose<40, drainage
positive gram
stain, culture
TB straw, acute-PMN, chronic- <7.4,20%<7.3 positive AFB mesothelial cell<5%
lymphocyte smear,culture,
ADA>60
aspergillosis lymphocyte, mesothelial cell positive culture septate hyphae
Malignancy
lung, breast serous, lymphocyte, macrophage, >,<7.3 postive cytology/pleural tissue
mesothelial cell
lymphoma serous lymphocyte >7.3,20%<7.3 positive cytology, chemotherapy
flow cytometry
Connective tissue disease
SLE serous, PMN >7.3, LE cells low complement, pleural
20%<7.3 ANA>1:160
RA lymphocyte <7.2 glucose<30 low complement, RF>1:320

pulmonary embolism straw, PMN >7.3 none

pancreatitis , PMN 7.3-7.35 pleural/serum 60%
amylase>1
chylothorax milky, turbid lymphocyte >7.4 pleural TG>110 trauma, surgery,
lymphoma
esophageal rupture early:serous, PMN early:pH>7.3, amylase
late:turbid, Late:pH<7.3

asbestos exposure PMN,monos,eosinophil >7.3 history of
exposure
CHF:congestive heart failure; RA:rheumatoid arthritis; NS:nephrotic syndrome; PD:peritoneal dialysis; RF:rheumatoid factor, ANA:antinuclear antibody

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